All states' health care plans are not created equal.
Under the Affordable Care Act, states could qualify for expanded Medicaid funds from the federal government as of Jan. 1, 2014. The ACA provides that if a state opts to expand its Medicaid program, the federal government will cover all of the state's costs to cover newly eligible people for the first three years, and at least 90 percent of the costs after that. But in conservative states where opposition to the ACA is running high, many state governments have refused to accept the expansion funds, arguing that Medicaid is a fiscally untenable system.
According to estimates from the Kaiser Family Foundation, that means more than 4.8 million Americans who could have their health insurance covered by the government may instead have to find their own coverage.
The so-called expansion means that each state would be able to increase the number of its residents that qualify for Medicaid coverage. It does so by setting the income eligibility level for Medicaid at 138 percent of the federal poverty line—or approximately $27,000 for a family of three. It would also expand coverage for non-elderly adults who don't have children.
But the Supreme Court ruled in 2012 that states have the option to reject the new federal standard. (In fact, states aren't obligated to subscribe to the Medicaid program at all—but they all do.) So far, 19 states have decided to reject the Medicaid expansion, and 24 states will not implement the expansion this year. Five states are still debating whether to accept the money—Utah, Missouri, Indiana, Pennsylvania, and Virginia. Of the 19 states that are currently refusing the Medicaid expansion, only one—Montana—has a Democratic governor.
Among the states that have rejected the expansion, Wisconsin is an exception. While every other state has seen a net loss in the number of people covered, Wisconsin has actually seen a net gain. That's because Gov. Scott Walker instituted a new Medicaid program that disqualified some adults living above the poverty line from receiving Medicaid, but also added coverage for adults living below the poverty line.
So while around 75,000 adults in Wisconsin were kicked off the state Medicaid program, known as BadgerCare, about 82,000 adults were given coverage under the state's new program. For those uninsured residents who live above the poverty line but below 200 percent of the line, they'll have to switch over to the federal exchange.
All told—and including states that have not yet decided whether to accept the expansion funds—more than 4.8 million people are stuck in the Medicaid eligibility gap. That works out to about 10 percent of Americans living in poverty, or 1.4 percent of the total U.S. population.
The biggest gaps are in states like Texas, where more than 1 million people who would qualify for Medicaid under the expansion will be left uninsured. Last April, Texas Gov. Rick Perry told reporters that the Medicaid system would need to be reformed before he would consider expanding the program.
"Seems to me April Fool's Day is the perfect day to discuss something as foolish as Medicaid expansion, and to remind everyone that Texas will not be held hostage by the Obama administration's attempt to force us into the fool's errand of adding more than a million Texans to a broken system," Perry said then.
These numbers can be hard to parse through. But the philosophical stand these states are taking against the Affordable Care Act could have very real effects on their poorest residents.